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A care coordination note documents the work of organizing a client's care across providers: contacts made, referrals and their status, consent to share information, handoffs, and outcomes. Therapists, case managers, and integrated care teams write one whenever they arrange, share, or follow up on care with someone outside the session. Most run 75 to 250 words.
Therapists, case managers, care coordinators, integrated behavioral health teams
Care team, next provider, supervisors, payers, auditors
75 to 250 words · 5 to 10 minutes by hand (clinical team estimate)
Operational continuity note (compare: case management note, transfer-of-care summary)
When arranging, sharing, or following up on care across providers
A documentation convention; the billable care-management services it supports carry specific payer rules
A care coordination note records one kind of clinical work: organizing a client's care across the people involved in it, and sharing the information each of them needs. The framing has a clear source. The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as "deliberately organizing patient care activities and sharing information" among everyone concerned with a patient's care. Clinicians also call these contact notes, coordination-of-care notes, or collateral-contact notes, and the activity often sits inside a broader case management note.
One distinction prevents most of the confusion. A care coordination note is documentation of coordination activity, not a billable service, and it has no CPT code of its own. Medicare defines separate service families for coordinating care over time, including Chronic Care Management, Transitional Care Management, and Behavioral Health Integration, and each carries its own consent, care-plan, and time requirements. Writing a care coordination note does not by itself make the time billable. When you are documenting to support one of those services, the note has to meet that service's rules; when you are simply recording that you called a psychiatrist or sent a referral, it is an ordinary entry in the client's record.
Care coordination notes appear wherever a client's care crosses a boundary: a referral to a psychiatrist or a primary care provider, a discharge from a higher level of care, a school or agency involved in a young person's treatment, or a benefits system that needs a report. Case managers and care coordinators write them constantly, and solo therapists write them whenever they pick up the phone about a shared client. The note earns its place when coordination is frequent or high stakes, such as a treatment plan that depends on other providers doing their part, or a care transition where a dropped handoff can undo months of work. For the clinical reasoning those handoffs carry forward, see the case formulation.
A care coordination note is short and operational. It answers four questions a reviewer will ask: why did coordination happen, who did you contact, what were you allowed to share, and what happens next. These sections cover all four, and each carries the pitfall that most often weakens it.
Reason for coordination. The trigger: a new referral, a care transition, a risk event, or a scheduled review. State it in one line so the note has a purpose a reader can see. Pitfall: a coordination note with no stated reason, which reads as time spent for no documented purpose.
Participants and contacts. Who you contacted: name, role, organization, the method (phone, secure message, portal, fax), the direction (you reached out or they reached you), and the date. Pitfall: "coordinated with the PCP" with no who, when, or how, which a reviewer cannot verify.
Consent to share. The basis for the disclosure: the treatment exception, a signed release of information on file, or a substance use disorder consent under 42 CFR Part 2. Pitfall: sharing protected information without naming the authority that permits it.
Referrals and status. Each referral, to whom and for what, plus where it sits in the loop: sent, accepted, scheduled, completed, results returned. Pitfall: documenting the referral you sent and never closing the loop, so no one knows whether the client arrived.
Information exchanged and actions. What you shared or requested, the decisions reached, and the tasks assigned with an owner. Pitfall: "discussed the case" with none of the substance or the decisions.
Outcome and follow-up. The result of the coordination, the next step, who owns it, and the date or trigger for the next check. Pitfall: a follow-up with no owner and no date, so the task falls through the transition.
Client: [initials] Date: Clinician: Reason for coordination: [new referral / care transition / risk event / review] Participants and contacts: [name, role, org, phone/portal/fax, outreach or received, date] Consent to share: [treatment exception / signed ROI on file (date) / 42 CFR Part 2 consent (date) / N/A] Referral(s) and status: [to whom, for what, urgency; sent / accepted / scheduled / completed / results returned] Information exchanged and actions: [what was shared or requested; decisions; tasks and owners] Outcome and follow-up: [result; next step; responsible party; next check date or trigger] Time spent (if billing a care-management service): [total minutes; who performed] Clinician signature/credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: an adult client re-entering outpatient care after an inpatient psychiatric stay, with the therapist coordinating the handoff to primary care and psychiatry. All details are fictional.
Client: R.K., 41 · Date: 07/09/2026 · Clinician: J. Rivera, LCSW
Reason for coordination: Care transition after inpatient psychiatric discharge on 07/07/2026; re-establishing outpatient care and confirming the handoff.
Participants and contacts: Phone call to County General discharge social worker (A. Alvarez, LCSW) 07/09 at 10:15, outbound. Secure message to PCP (Dr. Nguyen) 07/09. Portal message left for client 07/09.
Consent to share: Signed release of information on file dated 06/02/2026 authorizing exchange with the PCP and the inpatient team. No substance use disorder records involved.
Referrals and status: Psychiatry referral (Dr. Patel) for medication management sent 07/09, accepted, first appointment scheduled 07/16. PCP follow-up scheduled 07/14. Discharge summary requested from County General, received 07/09.
Information exchanged and actions: Shared the current medication list and updated safety plan with the PCP. Confirmed the client has a two-week medication supply. Reconciled discharge medications against the outpatient record; no discrepancies.
Outcome and follow-up: Handoff complete; psychiatry and PCP appointments booked and therapy resumes 07/13. Writer to confirm the client attended psychiatry and reconcile any medication changes by 07/17.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsA care coordination note is part of the designated record set: the client can request it, other providers may rely on it, and a payer can audit it. Most coordination is a disclosure for treatment, and under HIPAA a provider may share protected health information with another provider for treatment without the client's authorization (45 CFR 164.506); the rule defines treatment to include the coordination of care, and the minimum-necessary standard does not apply to disclosures for treatment. Two limits matter in behavioral health. Substance use disorder records from a Part 2 program generally need the client's written consent to share (42 CFR Part 2), and true psychotherapy notes stay segregated with their own authorization. Naming the consent basis in the note is what shows you applied the right rule.
The confusion worth resolving is billing. Recording that you coordinated care does not make the time reimbursable, and a care coordination note has no billing code of its own. The care-management services that pay for coordination, including Chronic Care Management and Behavioral Health Integration, each require specific elements: the patient's consent to the service, a documented care plan, and a running total of coordination time performed by identified staff. HIPAA permitting the disclosure is a separate question from the payer requiring that consent. Clinical staff may document coordination under the billing provider's general supervision, and the provider authenticates the entry. The note is a convention; those service requirements are payer policy, and an auditor checks the note against them. If you are handing a client off rather than coordinating over time, a treatment plan or a transfer summary may fit the moment better.
The errors that draw audit attention cluster around coordination that gets billed as a care-management service. In an August 2021 audit (A-07-19-05122), the HHS Office of Inspector General found about $1.9 million in overpayments across 50,192 Chronic Care Management claims from 2017 and 2018, driven mostly by duplicate and overlapping billing rather than by the coordination work itself. The BastionGPT Clinical Advisory Board sees the same documentation gaps most often in care coordination note reviews:
BastionGPT is specifically trained, tuned, and clinically tested on care coordination notes.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
Most care coordination notes run 75 to 250 words and take 5 to 10 minutes to write. It is an operational note: long enough to show who you contacted, what you were allowed to share, and what happens next, short enough to write right after the call. Length beyond that rarely adds anything a reviewer needs.
They overlap, but a care coordination note is narrower. It documents a specific coordination episode: the contacts, referrals, consent status, and follow-up. A case management note is broader, tracking a client's needs, goals, barriers, and progress against a care plan over time. Coordination activity often lives inside case management work, and many teams keep both.
Coordination by itself is not separately billable, and a care coordination note has no billing code. Time can count only inside an approved care-management service such as Chronic Care Management, Transitional Care Management, or Behavioral Health Integration, each with its own rules. Chronic Care Management, for example, expects at least 20 minutes of clinical-staff coordination time in a month, the patient's consent to the service, and a care plan. See the treatment plan those services build on.
Under HIPAA you may share protected health information with another provider for treatment without a separate authorization, and coordinating a client's care counts as treatment (45 CFR 164.506). Two caveats: substance use disorder records under 42 CFR Part 2 need the client's written consent, and billing a care-management service requires documenting the patient's consent to that service. Record which basis applies. The psychotherapy notes authorization page covers the separate rules for process notes.
A referral letter asks another provider to take on a piece of care. A transfer-of-care summary hands the whole case to a new provider. A care coordination note documents the ongoing work of keeping providers aligned while care continues: the calls, the referral tracking, the consent status, and the follow-up. You often write a coordination note about a referral you sent.
Any qualified member of the care team can document coordination. When the work supports a billable care-management service, Medicare lets clinical staff perform and document it under the billing provider's general supervision, and the billing provider authenticates the entry. Note who did the work and who is billing, and sign with your credentials.
There is no single HIPAA retention rule for patient records; retention comes from state, payer, and program rules. Medicare commonly points to a seven-year window for records that support claims, and states set their own minimums, often longer for records of minors. Because a coordination note can support a billed care-management service, keep it at least as long as the claim rules require and check your jurisdiction.
Yes. Give it your contact log, referral details, and a few bullets, and it drafts a structured coordination note for your review. It can also pull a coordination summary together from a discharge summary and referral updates, and flag open referral loops or a missing consent basis before you sign. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The compliance claims on this page trace to these authorities, last verified July 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.